January 30 2013
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e lectronic s ubmission of Medical Documentation (esMD) electronic Determination of Coverage ( eDoC ) Workgroup Charter Review. January 30 , 2013. Welcome and Introductions. Melanie Combs-Dyer, RN Deputy Director, CMS / OFM / Provider Compliance Group. Dan Kalwa

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January 30 , 2013

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January 30 2013

electronic submission of Medical Documentation (esMD)electronic Determination of Coverage (eDoC) WorkgroupCharter Review

January 30, 2013


January 30 2013

Welcome and Introductions

Melanie Combs-Dyer, RN

Deputy Director,CMS / OFM / Provider Compliance Group

Dan Kalwa

Health Insurance Specialist,CMS / OFM / Provider Compliance Group

Michael Handrigan, MD

Medical OfficerCMS / OFM / Provider Compliance Group

Robert Dieterle,

Initiative Coordinator

Viet Nguyen, MD

Chief Medical Information Officer

Systems Made Simple, Inc.

Mark D Pilley, MD AAFP, AADEP, ABQAURP

Medical Director

StrategicHealthSolutions, LLC

2


January 30 2013

Agenda

3


January 30 2013

Electronic Determination of Coverage (eDoC)

4


Edoc general workflow

eDoC General Workflow

Patient

LCMP

Physician

Specialist /

Service Provider

Templates and Rules

Payer

5


Scope

Scope

Out of Scope

Specific provider service implementations

EHR implementations

Provision of Information exchange services (e.g. HISPs for Direct)

  • In Scope – Phase 1

  • Structured and unstructured data requirements

  • Exchange standards

  • Digital signature requirements

  • In Scope – Phase 2

  • Templates for Structured Data Capture (SDC)

  • Decision Support (rules, data capture, order sentences and behaviors) (HeD)


Edoc pmd workflow

eDoC PMD Workflow

Patient

Signed Document

3

11

1

LCMP

Physician

DME Supplier

2

5

6

10c

4

8

7

9a

10a

10b

9b

Templates and Rules

Payer

Payer

7


Edoc workgroup structure

eDoC Workgroup Structure

8


Structured information for pmd

Structured Information for PMD

  • Based on clinical template developed by CMS

    • Available at http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/Downloads/Suggested-PMD-Electronic-Clinical-Template-v98-posted-11-02-12.pdf

  • Supports

    • Data collection by providers during face-to-face evaluation

    • Reporting of clinical information for coverage determination

    • Clinical decision support and automated determination of coverage

9


Components of pmd clinical template

Components of PMD Clinical Template

  • Chief Complaint

  • History of Present Illness

  • Past Medical History

  • Review of Systems

  • Physical Exam

  • Patient Assessment and Plan

  • Physician Information and 7 Element Order

  • Components focused on data to support a PMD order and coverage

10


Evaluation process for pmd clinical template

Evaluation Process for PMD Clinical Template

  • Examination of individual clinical elements for each section of the template

  • Determine if a clinical element is codifiable (e.g. Diagnosis), requires a narrative (e.g. History of Present Illness), or is mixed (e.g. Review of Systems)

  • Compare coded elements to existing standard coding systems (e.g. SNOMED-CT, ICD) and CDA components

  • Develop Templated CDA based on consensus and best practices

11


Edoc workgroup structure1

eDoC Workgroup Structure

12


Structured data capture sdc

Structured Data Capture (SDC)


Sdc standards

SDC Standards


Edoc workgroup structure2

eDoC Workgroup Structure

15


Clinical decision support

Clinical Decision Support


Clinical decision support1

Clinical Decision Support


Edoc timeline

eDoC Timeline

July ‘13

Mar ‘13

May ‘ 13

Aug ‘13

Jun ‘13

Feb ‘13

Apr ‘13

Pre-Discovery

Workgroup Charter/Scope

Kick-Off

PMD Phase 1

Pilots (TBD)

PMD Phase 1

Implementation Guide

Use Case #1: PMD Phase 1

Standards/Data Model/Harmonization

PMD Phase 1

Sub Workgroup PMD Structured Data

PMD Phase 2

Implementation Guide

Use Case #1: PMD Phase 2

Standards/Data Model/Harmonization

PMD Phase 2 (TBD)

Sub Workgroup PMD Data Capture Template

Sub Workgroup PMD Decision Support

18

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Summary

Summary

eDoC workgroup identifies Best Practice for:

  • Payer interaction with providers for determination of coverage

  • Developing, delivering and using structured documentation templates to support coverage determination

  • Developing and instantiating decision support rules to facilitate provider decision making in light of payer standards

  • Addressing Author of Record requirements

  • Secure electronic communication between payers, provider, suppliers and beneficiaries

  • Creating implementation guides for payers and providers (usually via HIT vendors) for all required eDoC processes and transactions

19


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